361800217-9-11-2020-18-AS-EMAN-BTVNJF-20200928103015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800217
Report Date: 09/10/2020
Date Signed: 09/11/2020 03:27:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2020 and conducted by Evaluator Naisha Kendrix

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200827101056

FACILITY NAME:	FERN HOME III LLC		FACILITY NUMBER:	361800217
ADMINISTRATOR:	GUBALANE, JOI MAE		FACILITY TYPE:	740
ADDRESS:	1841 SHEDDEN DRIVE		TELEPHONE:	(909) 894-3131
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 3	DATE:	09/10/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Joi Mae Gubalane		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility has insufficient funds to meet resident's needs.

Food service is inadequate.

INVESTIGATION FINDINGS:

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Due to the Department’s implementation, and in following current public health guidance, this report will be delivered via telephone. Licensing Program Analyst (LPA) Naisha Kendrix identified herself to the Administrator, Joi Mae Gubalane, and stated the reason for the call was to deliver findings for the above allegations.

During the investigation, LPA conducted five interviews of staff and residents, toured the facility, reviewed documentation, and researched the business license for Fern Home III LLC. LPA toured the facility via phone and observed the lights were on, the water was working, there was the required amount of perishable and non-perishable food present, and the facility phone was working. LPA reviewed the payroll invoices for staff, the facility rental agreement, and copies of recent utility bills. LPA found the LLC was active, utilities were on, staff was paid, and the licensee has control of the property.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha Kendrix	TELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200827101056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FERN HOME III LLC	FACILITY NUMBER: 361800217
	VISIT DATE: 09/10/2020

NARRATIVE

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Five of five interviews conducted with staff and residents revealed the food service is sufficient and residents are satisfied with the food provided. LPA reviewed a monthly food budget, menu, and food receipts. The sample menu plan indicated three meals a day, including sacks, and the amount to be served. The receipts and budget showed food purchased in the month of August 2020.

Interviews that were conducted could not corroborate the allegation of the facility has insufficient funds to meet resident’s needs or that the food service is inadequate. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted where this report was reviewed with the administrator. LPA will email the report to the administrator for a signature. The administrator returned the signed report within 24 hours of receipt.

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha Kendrix	TELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

LIC9099 (FAS) - (06/04)

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